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EGGIE SALON STUDIO CONSULTATION INTAKE FORM
I am interested in getting to know you better, understanding your journey with cancer, and specifically learning about your experience with your hair! To help me in preparing for your appointment, please take a moment to fill out this consultation form. Your valuable insights will greatly assist me in tailoring my approach and providing the best possible care. I appreciate your cooperation and look forward to meeting you soon!
-Rachel Eggie Gibbs-
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Email
*
Your email
Full Name
*
Your answer
Cell Phone Number
*
Your answer
What is your mailing address?
*
Your answer
Date of Birth
*
Your answer
What is the purpose of your visit today?
*
Consultation/Wig Fitting
Wig Cutting
Hair Topper
Initial Appointment for first Haircut
Follow-up Haircut
How many months post-chemo are you?
*
1-3 Months
3-6 Months
6-9 Months
9-12 Months
12-18 Months
18+ Months
I have not yet started treatment
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